P.S. asks, "How do I know that the tube is the correct length?"
Answer: It is important to ensure that the tube is neither too short nor too long. If the tube is too short, it can be easily dislodged. If too long, the tube can become "mainstemmed" in the right bronchus. It can also cause other symptoms such as high airway pressures, discomfort, or continuous coughing by its constant irritation against the tracheal wall.
In order to determine optimal position of the tube within the airway, a chest x-ray can be beneficial, but a bronchoscope can be used to directly visualize the position of the tube.
Tuesday, September 13, 2011
Tuesday, August 9, 2011
International Conference on Tracheostomies
There is a new international symposium on Advanced Tracheostomy Management and Prolonged Mechanical Ventilation. It will be held in Melbourne, Australia on September 1-2. Check out their website at: https://sites.google.com/site/tracheostomyconference2011/.
I'm very excited about this conference as it will be the first conference dedicated specifically to tracheostomies. I have been invited to be part of the panel on Tricky Tracheostomy Cases.
LLM
I'm very excited about this conference as it will be the first conference dedicated specifically to tracheostomies. I have been invited to be part of the panel on Tricky Tracheostomy Cases.
LLM
Saturday, July 23, 2011
Trach Dislodgement
B.L. asks, "How does tracheostomy dislodgement happen?"
Answer: Dislodgement can be one of the most serious complications of having a tracheostomy. Dislodgement can be even more serious than complete decannulation; because when the tube is completely removed from the stoma (decannulation), the problem is clearly visible. However, when the tube is dislodged, it may not be so obvious. In this case, the tube is still in the neck; however, the tip of the tube is not within the trachea and instead is positioned within the tissue anterior to the trachea, most often called a false passage.
Numerous attempts to replace the tube can enlarge the false passage, making subsequent attempts to replace it nearly always unsuccessful.
There are several risk factors for tracheostomy dislodgement: a tube that is too short, traction against the tube, edema of the neck, obesity or a thick neck, and excessive coughing or agitation.
Specific techniques of tube replacement depend on the maturity of the stoma and whether or not the patient is able to breathe around the tube. These are discussed in more detail in our recent article in the "The Dreaded False Passage: Management of Tracheostomy Tube Dislodgement", Morris & Afifi, Journal of Emergency Medicine, 33(8).
Answer: Dislodgement can be one of the most serious complications of having a tracheostomy. Dislodgement can be even more serious than complete decannulation; because when the tube is completely removed from the stoma (decannulation), the problem is clearly visible. However, when the tube is dislodged, it may not be so obvious. In this case, the tube is still in the neck; however, the tip of the tube is not within the trachea and instead is positioned within the tissue anterior to the trachea, most often called a false passage.
Numerous attempts to replace the tube can enlarge the false passage, making subsequent attempts to replace it nearly always unsuccessful.
There are several risk factors for tracheostomy dislodgement: a tube that is too short, traction against the tube, edema of the neck, obesity or a thick neck, and excessive coughing or agitation.
Specific techniques of tube replacement depend on the maturity of the stoma and whether or not the patient is able to breathe around the tube. These are discussed in more detail in our recent article in the "The Dreaded False Passage: Management of Tracheostomy Tube Dislodgement", Morris & Afifi, Journal of Emergency Medicine, 33(8).
Friday, June 24, 2011
Trach Button vs. Trach Tube
Dr. S.A. asks, "I just received a rehab patient with a trach button who has developed pneumonia. Can I just replace the button with a regular trach?"
Answer: A trach button is often placed to maintain the stoma while the patient is gaining strength through rehabilitation. The benefit of a button is that it provides no resistance within the airway, yet it maintains the stoma in case an artificial airway is needed. If there is concern about secretions and the need for frequent suctioning, it is best to replace the button with a regular tracheostomy tube. Otherwise, one would need to open the button every time the patient needs suctioning, and the introduction of a suction catheter would be directed toward the posterior tracheal wall.
One must realize that the trach button consists of three parts: the tracheal cannula, the closure plug, and a series of spacers to adjust to the exact length of the stoma. In order to remove the button, first remove the closure plug with the spacers. This will release the tension against the distal petals of the cannula. The cannula can then be removed easily and replaced with a tracheostomy tube.
Answer: A trach button is often placed to maintain the stoma while the patient is gaining strength through rehabilitation. The benefit of a button is that it provides no resistance within the airway, yet it maintains the stoma in case an artificial airway is needed. If there is concern about secretions and the need for frequent suctioning, it is best to replace the button with a regular tracheostomy tube. Otherwise, one would need to open the button every time the patient needs suctioning, and the introduction of a suction catheter would be directed toward the posterior tracheal wall.
One must realize that the trach button consists of three parts: the tracheal cannula, the closure plug, and a series of spacers to adjust to the exact length of the stoma. In order to remove the button, first remove the closure plug with the spacers. This will release the tension against the distal petals of the cannula. The cannula can then be removed easily and replaced with a tracheostomy tube.
Saturday, June 4, 2011
Cuff Leaks
R.B. asks, "When a patient is on the ventilator, what causes a leak in the cuff?"
Answer: There are many causes to a cuff leak. First, to clarify, it is rare that a leak within the cuff actually happens. What happens most often is a leak around the cuff. This leak around the cuff is usually caused by a tube that is too small, or by an overinflated cuff.
When a tube is too small for the airway, most clinicians attempt to compensate by overinflating the cuff. This may solve the problem temporarily; however, the problem is that overinflation of the cuff changes a low-pressure cuff into a high-pressure cuff, creating many more problems later on. A small tube should be changed to one of proper size in order to ensure an adequate seal.
Chronic overinflation of the cuff, even in a tube of proper size, can cause the tracheal tissue to stretch in the area of the cuff. This is called tracheomalacia. In this case, the tube should be changed to a longer one to extend past the area of tracheomalacia.
Answer: There are many causes to a cuff leak. First, to clarify, it is rare that a leak within the cuff actually happens. What happens most often is a leak around the cuff. This leak around the cuff is usually caused by a tube that is too small, or by an overinflated cuff.
When a tube is too small for the airway, most clinicians attempt to compensate by overinflating the cuff. This may solve the problem temporarily; however, the problem is that overinflation of the cuff changes a low-pressure cuff into a high-pressure cuff, creating many more problems later on. A small tube should be changed to one of proper size in order to ensure an adequate seal.
Chronic overinflation of the cuff, even in a tube of proper size, can cause the tracheal tissue to stretch in the area of the cuff. This is called tracheomalacia. In this case, the tube should be changed to a longer one to extend past the area of tracheomalacia.
Sunday, May 29, 2011
Fenestrated Tubes
T.H. asks, "What is the purpose of a fenestrated tracheostomy tube?"
Answer: The word fenestration comes from the French word, "la fenetre", meaning 'window'. So a fenestrated tube is one with a window, or a hole, on the dorsal shaft of the tube. The purpose of this hole is to decrease the resistance of the tube when breathing around it, usually allowing the patient to speak.
The biggest problem regarding fenestrated tubes is that most clinicians do not realize that these tubes must be fit precisely so that the fenestration lies centrally in the airway. If it does not, granulation tissue will grow within the fenestration, making removal of the tube a surgical challenge. Only those with specialized training should attempt to remove a fenestrated tube, or hemorrhage could result.
Most fenestrated tubes require a custom fit. It is rare that an off-the-shelf fenestrated tube will fit an average patient. Because of these precautions, it is usually easier and safer to fit a different type of tube to allow a patient to speak. If a fenestrated tube remains the best option, then it is imperative that it is precisely measured to fit to the patient.
Answer: The word fenestration comes from the French word, "la fenetre", meaning 'window'. So a fenestrated tube is one with a window, or a hole, on the dorsal shaft of the tube. The purpose of this hole is to decrease the resistance of the tube when breathing around it, usually allowing the patient to speak.
The biggest problem regarding fenestrated tubes is that most clinicians do not realize that these tubes must be fit precisely so that the fenestration lies centrally in the airway. If it does not, granulation tissue will grow within the fenestration, making removal of the tube a surgical challenge. Only those with specialized training should attempt to remove a fenestrated tube, or hemorrhage could result.
Most fenestrated tubes require a custom fit. It is rare that an off-the-shelf fenestrated tube will fit an average patient. Because of these precautions, it is usually easier and safer to fit a different type of tube to allow a patient to speak. If a fenestrated tube remains the best option, then it is imperative that it is precisely measured to fit to the patient.
Saturday, May 21, 2011
Inflated or Deflated?
Respiratory therapist, S.S., asks, "If the patient has been weaned from the ventilator, should the cuff be inflated or deflated?
Answer: The inflated cuff provides a seal of the airway in order to effectively ventilate and oxygenate the patient. When the patient no longer requires the ventilator, it is usually best to deflate the cuff because of other problems that an inflated cuff can cause (tracheomalacia, tracheal stenosis, etc.). However, the exception to this rule is the patient who cannot protect his airway. Those who pose a risk for aspiration should have an inflated cuff because their cough and/or swallow reflex is not strong enough to prevent secretions from entering the airway.
When patients require cuff inflation, we need to ensure that the cuff is inflated enough to prevent leakage around the cuff, but not exert too much pressure against the trachea. Measured cuff pressure should be in the range of 20-25 cm H2O.
In the absence of measured cuff pressure, a good clinical technique is minimal leak technique. In this case the cuff is completely deflated (first, use a soft suction catheter to remove secretions from the oropharynx), then inflated until a leak is no longer heard. At that point, 1/2 ml of air is withdrawn from the cuff, enough to seal the airway, but minimizing excess pressure against the trachea.
It is important to note that clinical opinion varies on this point. If the patient is in the ICU and managed by the critical care team, their goal is to ventilate the patient and may not be as concerned with high cuff pressures in the short term. However, to prevent more long term complications, it is wise to minimize cuff pressure as much as clinically warranted.
Answer: The inflated cuff provides a seal of the airway in order to effectively ventilate and oxygenate the patient. When the patient no longer requires the ventilator, it is usually best to deflate the cuff because of other problems that an inflated cuff can cause (tracheomalacia, tracheal stenosis, etc.). However, the exception to this rule is the patient who cannot protect his airway. Those who pose a risk for aspiration should have an inflated cuff because their cough and/or swallow reflex is not strong enough to prevent secretions from entering the airway.
When patients require cuff inflation, we need to ensure that the cuff is inflated enough to prevent leakage around the cuff, but not exert too much pressure against the trachea. Measured cuff pressure should be in the range of 20-25 cm H2O.
In the absence of measured cuff pressure, a good clinical technique is minimal leak technique. In this case the cuff is completely deflated (first, use a soft suction catheter to remove secretions from the oropharynx), then inflated until a leak is no longer heard. At that point, 1/2 ml of air is withdrawn from the cuff, enough to seal the airway, but minimizing excess pressure against the trachea.
It is important to note that clinical opinion varies on this point. If the patient is in the ICU and managed by the critical care team, their goal is to ventilate the patient and may not be as concerned with high cuff pressures in the short term. However, to prevent more long term complications, it is wise to minimize cuff pressure as much as clinically warranted.
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